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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">With the advent of antiretroviral therapy &#40;ART&#41;&#44; survival of human immunodeficiency virus &#40;HIV&#41;-infected patients has increased&#44; and HIV has become&#44; in those who adhere to ART&#44; a chronic disease with long life expectancy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In these circumstances&#44; degenerative diseases&#44; particularly cardiovascular disease &#40;CVD&#41;&#44; sometimes premature&#44; have become important problems in the follow-up of these patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cardiovascular disorders initially associated with HIV included left ventricular dysfunction&#44; pericardial effusion&#44; infective endocarditis&#44; arrhythmias associated with long QT interval and pulmonary hypertension&#44; as well as atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; in recent years&#44; accelerated atherosclerosis and coronary artery disease have emerged as major causes of cardiovascular mortality and morbidity in HIV-infected patients&#46; Although total mortality in HIV patients has fallen in the last 10 years&#44; cardiovascular mortality has increased significantly over the same period&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The reasons for this accelerated atherosclerosis and the increased incidence of myocardial infarction in HIV patients are not fully known&#46; The causes are probably multiple&#44; with associations of factors&#44; including endothelial dysfunction with increased expression of adhesion molecules and platelet aggregation&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> side effects of ART including protease inhibitor-associated dyslipidemia and insulin resistance&#44; and a heavy burden of traditional risk factors such as smoking&#46; Paradoxically&#44; in general&#44; the cardiovascular risk factors of HIV-infected individuals are treated less than those of uninfected persons&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">HIV infection itself appears to be an independent risk factor for coronary artery disease&#46; HIV patients without major cardiovascular risk factors present about twice the risk of myocardial infarction compared to non-infected individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After a coronary event&#44; HIV-infected individuals appear to present a worse prognosis&#44; with unexpectedly high restenosis rates after percutaneous coronary intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Against this background&#44; the current issue of the <span class="elsevierStyleItalic">Journal</span> presents a paper by Policarpo et al&#46; on cardiovascular risk estimation in HIV-infected patients&#44; assessing and comparing the usefulness of three cardiovascular risk algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Considering the importance of CVD in HIV-infected individuals&#44; all papers in this field are to be welcomed&#44; since they focus on what is clearly an unsolved problem&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In their study&#44; the authors estimate cardiovascular risk using the European Systematic Coronary Risk Evaluation &#40;SCORE&#41;&#44; the Framingham risk score &#40;FRS&#41; and the Data Collection on Adverse Events of Anti-HIV Drugs &#40;DAD&#41; score&#46; The latter is designed to assess the cardiovascular risk of HIV-infected individuals and includes exposure to HIV treatment as well as traditional risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Analyzing 571 patients from a total of 3000 HIV-infected patients followed at their Department of Infectious Diseases&#44; Policarpo et al&#46; conclude that there are significant correlations between the three risk scores&#44; with 4&#46;4&#37; of the patients being classified as high-risk with SCORE&#44; 10&#46;3&#37; with DAD&#44; and 20&#46;5&#37; with the FRS&#46; This result was predictable&#44; as all risk algorithms share the same parameters &#40;conventional risk factors&#41; to estimate overall cardiovascular risk&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the same time&#44; the authors found a high level of conventional risk factors in HIV patients&#44; with 53&#37; being smokers&#44; waist circumference above the cut-off in 42&#37;&#44; obesity or overweight in 40&#37; and metabolic syndrome in nearly 33&#37;&#46; In general&#44; the group on ART presented a worse risk profile than the treatment-naive group&#44; reflecting the older age of the former group as well as the atherogenic potential of the therapy&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The article has several positive points&#44; including the importance of the subject&#44; the large sample under analysis&#44; the identification of conventional cardiovascular risk factors in an HIV population&#44; and the use of three algorithms to estimate cardiovascular risk in HIV-infected individuals&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; there are also some limitations&#46; From my standpoint&#44; the main limitation of the paper is the lack of a gold standard for assessing cardiovascular risk&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The authors compare three risk algorithms&#44; with significant correlations but quite different results &#40;the proportion of subjects classified as at high risk ranging from 4&#46;4&#37; to 20&#46;5&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Bearing in mind the high cardiovascular risk of HIV patients&#44; it could be assumed that the most inclusive score &#40;FRS&#41; is the most applicable&#44; but in fact we do not know which is the most appropriate to assess the actual cardiovascular risk in HIV patients&#46; Moreover&#44; different scores analyze different endpoints&#44; leading to different results&#46; SCORE assesses cardiovascular mortality over 10 years&#44; while the FRS assesses the incidence of CVD&#44; including fatal and non-fatal events&#44; over the same period&#46; In these circumstances&#44; the FRS is bound to be more inclusive than SCORE&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Only a prospective study to assess what happens to patients at different risk levels could validate a particular risk score&#46; Such a study would present ethical limitations&#58; HIV patients with conventional risk factors must be treated&#44; not observed&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">An alternative to validate the utility of a risk score in these patients could be to assess intermediate end-points&#44; such as carotid intima-media thickness or coronary artery calcium score&#46; Demonstration of a close relationship between a risk score and an intermediate end-point would support the usefulness of that score to access coronary risk in HIV patients&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally&#44; what advice can be given to physicians and HIV patients to prevent CVD&#63;</p><p id="par0100" class="elsevierStylePara elsevierViewall">HIV patients under ART should be aware that CVD is a real threat to their life&#44; in terms of survival as well as quality&#44; and should adopt healthy habits&#44; not smoking and actively controlling their cardiovascular risk factors&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Physicians should be aware of HIV patients&#8217; cardiovascular risk&#44; assess that risk and&#44; whatever the algorithm&#44; bearing in mind the high baseline cardiovascular risk of these patients&#44; be prepared to intervene to achieve control of their cardiovascular risk factors&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Infectologists should aim to use ART drugs that are less likely to cause cardiovascular harm and should remain aware of their HIV patients&#8217; cardiovascular status&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Cardiologists should perform routine systematic cardiac monitoring&#44; assessing traditional risk factors&#44; paying special attention to major cardiovascular risk factors &#40;smoking&#44; hypertension&#44; diabetes and dyslipidemia&#41;&#44; and monitor risk factors and the cardiovascular status of HIV patients&#44; bearing in mind that a first cardiac accident can be fatal&#46; Cardiac assessment&#44; including echocardiography and other cardiac exams&#44; is often needed to determine whether generic symptoms&#44; such as fatigue&#44; result from the infectious disease or from a cardiac complication&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Considering the high risk level of these patients&#44; after behavioral intervention&#44; cardiovascular medication should begin early in the follow-up of cardiovascular risk factors&#46; When prescribing cardiovascular drugs such as statins&#44; 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Editorial comment
Cardiovascular risk in HIV-infected patients
Risco cardiovascular em doentes infetados com HIV
Roberto Palma Reisa,b
a New Medical School, Lisbon, Portugal
b Hospital Pulido Valente, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">With the advent of antiretroviral therapy &#40;ART&#41;&#44; survival of human immunodeficiency virus &#40;HIV&#41;-infected patients has increased&#44; and HIV has become&#44; in those who adhere to ART&#44; a chronic disease with long life expectancy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In these circumstances&#44; degenerative diseases&#44; particularly cardiovascular disease &#40;CVD&#41;&#44; sometimes premature&#44; have become important problems in the follow-up of these patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cardiovascular disorders initially associated with HIV included left ventricular dysfunction&#44; pericardial effusion&#44; infective endocarditis&#44; arrhythmias associated with long QT interval and pulmonary hypertension&#44; as well as atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; in recent years&#44; accelerated atherosclerosis and coronary artery disease have emerged as major causes of cardiovascular mortality and morbidity in HIV-infected patients&#46; Although total mortality in HIV patients has fallen in the last 10 years&#44; cardiovascular mortality has increased significantly over the same period&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The reasons for this accelerated atherosclerosis and the increased incidence of myocardial infarction in HIV patients are not fully known&#46; The causes are probably multiple&#44; with associations of factors&#44; including endothelial dysfunction with increased expression of adhesion molecules and platelet aggregation&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> side effects of ART including protease inhibitor-associated dyslipidemia and insulin resistance&#44; and a heavy burden of traditional risk factors such as smoking&#46; Paradoxically&#44; in general&#44; the cardiovascular risk factors of HIV-infected individuals are treated less than those of uninfected persons&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">HIV infection itself appears to be an independent risk factor for coronary artery disease&#46; HIV patients without major cardiovascular risk factors present about twice the risk of myocardial infarction compared to non-infected individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After a coronary event&#44; HIV-infected individuals appear to present a worse prognosis&#44; with unexpectedly high restenosis rates after percutaneous coronary intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Against this background&#44; the current issue of the <span class="elsevierStyleItalic">Journal</span> presents a paper by Policarpo et al&#46; on cardiovascular risk estimation in HIV-infected patients&#44; assessing and comparing the usefulness of three cardiovascular risk algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Considering the importance of CVD in HIV-infected individuals&#44; all papers in this field are to be welcomed&#44; since they focus on what is clearly an unsolved problem&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In their study&#44; the authors estimate cardiovascular risk using the European Systematic Coronary Risk Evaluation &#40;SCORE&#41;&#44; the Framingham risk score &#40;FRS&#41; and the Data Collection on Adverse Events of Anti-HIV Drugs &#40;DAD&#41; score&#46; The latter is designed to assess the cardiovascular risk of HIV-infected individuals and includes exposure to HIV treatment as well as traditional risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Analyzing 571 patients from a total of 3000 HIV-infected patients followed at their Department of Infectious Diseases&#44; Policarpo et al&#46; conclude that there are significant correlations between the three risk scores&#44; with 4&#46;4&#37; of the patients being classified as high-risk with SCORE&#44; 10&#46;3&#37; with DAD&#44; and 20&#46;5&#37; with the FRS&#46; This result was predictable&#44; as all risk algorithms share the same parameters &#40;conventional risk factors&#41; to estimate overall cardiovascular risk&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the same time&#44; the authors found a high level of conventional risk factors in HIV patients&#44; with 53&#37; being smokers&#44; waist circumference above the cut-off in 42&#37;&#44; obesity or overweight in 40&#37; and metabolic syndrome in nearly 33&#37;&#46; In general&#44; the group on ART presented a worse risk profile than the treatment-naive group&#44; reflecting the older age of the former group as well as the atherogenic potential of the therapy&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The article has several positive points&#44; including the importance of the subject&#44; the large sample under analysis&#44; the identification of conventional cardiovascular risk factors in an HIV population&#44; and the use of three algorithms to estimate cardiovascular risk in HIV-infected individuals&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; there are also some limitations&#46; From my standpoint&#44; the main limitation of the paper is the lack of a gold standard for assessing cardiovascular risk&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The authors compare three risk algorithms&#44; with significant correlations but quite different results &#40;the proportion of subjects classified as at high risk ranging from 4&#46;4&#37; to 20&#46;5&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Bearing in mind the high cardiovascular risk of HIV patients&#44; it could be assumed that the most inclusive score &#40;FRS&#41; is the most applicable&#44; but in fact we do not know which is the most appropriate to assess the actual cardiovascular risk in HIV patients&#46; Moreover&#44; different scores analyze different endpoints&#44; leading to different results&#46; SCORE assesses cardiovascular mortality over 10 years&#44; while the FRS assesses the incidence of CVD&#44; including fatal and non-fatal events&#44; over the same period&#46; In these circumstances&#44; the FRS is bound to be more inclusive than SCORE&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Only a prospective study to assess what happens to patients at different risk levels could validate a particular risk score&#46; Such a study would present ethical limitations&#58; HIV patients with conventional risk factors must be treated&#44; not observed&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">An alternative to validate the utility of a risk score in these patients could be to assess intermediate end-points&#44; such as carotid intima-media thickness or coronary artery calcium score&#46; Demonstration of a close relationship between a risk score and an intermediate end-point would support the usefulness of that score to access coronary risk in HIV patients&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally&#44; what advice can be given to physicians and HIV patients to prevent CVD&#63;</p><p id="par0100" class="elsevierStylePara elsevierViewall">HIV patients under ART should be aware that CVD is a real threat to their life&#44; in terms of survival as well as quality&#44; and should adopt healthy habits&#44; not smoking and actively controlling their cardiovascular risk factors&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Physicians should be aware of HIV patients&#8217; cardiovascular risk&#44; assess that risk and&#44; whatever the algorithm&#44; bearing in mind the high baseline cardiovascular risk of these patients&#44; be prepared to intervene to achieve control of their cardiovascular risk factors&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Infectologists should aim to use ART drugs that are less likely to cause cardiovascular harm and should remain aware of their HIV patients&#8217; cardiovascular status&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Cardiologists should perform routine systematic cardiac monitoring&#44; assessing traditional risk factors&#44; paying special attention to major cardiovascular risk factors &#40;smoking&#44; hypertension&#44; diabetes and dyslipidemia&#41;&#44; and monitor risk factors and the cardiovascular status of HIV patients&#44; bearing in mind that a first cardiac accident can be fatal&#46; Cardiac assessment&#44; including echocardiography and other cardiac exams&#44; is often needed to determine whether generic symptoms&#44; such as fatigue&#44; result from the infectious disease or from a cardiac complication&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Considering the high risk level of these patients&#44; after behavioral intervention&#44; cardiovascular medication should begin early in the follow-up of cardiovascular risk factors&#46; When prescribing cardiovascular drugs such as statins&#44; it is important to take into account the particular characteristics of these patients and to choose drugs that do not interfere with ART&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The initial approach to HIV patients was based on control of the infection&#46; When this is achieved&#44; to maintain the increase in life expectancy of HIV-infected individuals&#44; it is necessary to prevent and treat late complications of the disease&#44; including CVD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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ISSN: 08702551
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